Thalassemic syndromes are genetically determined disorders of hemoglobin synthesis with decreased production of either alpha or beta polypeptide chains of hemoglobin molecules. This reduced production results from markedly decreased amounts of globin messenger ribonucleic acid. The imbalance may result from many genetic lesions. (See the images below.)
Anteroposterior (AP) of both hands
AP and lateral of thoracolumbar spine
AP of abdomen for gallstones
AP of chest for cardiomegaly, congestive heart failure, and extramedullary hematopoiesis
However, conventional radiography may not show early extramedullary hematopoiesis, which is best seen on magnetic resonance imaging (MRI). Computed tomography (CT) scanning may be required to further evaluate faciomaxillary changes and to clearly define expansile lesions of the pelvis resulting from extramedullary hematopoiesis. [3, 4, 5, 6, 7, 8, 9, 10]
Radiographically, the skeletal response to marrow proliferation consists of expansion of the medulla, thinning of cortical bone, and resorption of cancellous bone, which results in a generalized loss of bone density. [3, 11] Frequently, small areas of lucency resulting from focal proliferation of marrow may be present, often demarcated by coarsened but less numerous trabeculae. In addition, the hypertrophic and hyperplastic marrow may perforate the cortex, proliferate subperiosteally, and stimulate a variety of periosteal responses. Depending on the bone, these factors may result in a variety of radiographic appearances.
In weight-bearing bones, the resorptive process preserves the primary trabeculae at the expense of secondary trabeculae. In the vertebral bodies, this results in a striated appearance resulting from thickened vertical trabeculae that stand out against the paucity of horizontal trabeculae (see the image below). In severely affected patients, biconcavity of the superior and inferior margins of the vertebral bodies or compression fractures may occur.
Skull and facial bones
In severely affected patients, a widening of the diploic space (medulla) with a thinning of the tables (cortices) occurs, frequently with complete obliteration of the outer table. New bone forms in response to marrow proliferation beneath the periosteum. These bony spicules may be seen radiographically and result in a classic "hair-on-end" appearance. Because it lacks hematopoietic marrow, the occipital bone usually is not involved. (See the image below.)
Proliferation of marrow within the frontal and facial bones impedes pneumatization of the paranasal sinuses. This results in hypertrophy of osseous structures and a consequent prominence of the lateral margins of the malar eminences, together with anterior and medial displacement of developing teeth. These features explain the clinical findings noted by Cooley. Characteristically, ethmoidal sinuses are not involved, a factor attributable to the absence of red marrow in the sinus walls.
In patients with more profound anemia, changes may be noted in the distal bones of the extremities. In the most severely affected patients, the phalanges reveal the above-noted changes of cortical thinning, osteopenia, and coarsening of the trabeculae and may lose their normal tubulation, which frequently results in a squared or sausage-shaped configuration. (See the image below.)
Fractures may occur, although less commonly than expected from the degree of osteoporosis (see the image below). The sedentary life these children are forced to live possibly may protect them from frequent injury. In severely affected patients, well-defined erosions of the periosteal margin of the cortex of the metaphysis or diaphysis may be identified.
Similarly to the long bones, the ribs may reveal a spectrum of radiographic findings that demonstrate the varied response of the medulla, cortex, and periosteum to proliferating marrow. Evidence of widening, generalized osteopenia or localized lucency resulting from hypertrophy and hyperplasia of marrow within the medulla may be seen. Cortical erosions may be pronounced and are considered to result from focal subperiosteal proliferation of marrow. (See the image below.)
A frequent finding has been referred to as the "rib-within-a-rib" appearance and is noted particularly in the middle and anterior portions of the ribs. The finding consists of a long linear density within or overlapping the medullary space of the rib and running parallel to its long axis (see the image below). This appearance is not noted in any other portion of the skeleton.
Another finding, which appears limited to the ribs, is the subcortical lucency, consisting of a sharply defined lucency at the margin of the cortex and medulla. This appears to result from erosion of the inner aspect of the cortex and adjacent medullary trabeculae by the leading edge of proliferating marrow. A highly characteristic appearance consists of bulbous expansion of the posterior, and to a lesser extent, anterior segments of the ribs, and frequently is associated with posterior or anterior soft tissue densities, which histologically represent hematopoietic marrow.
In the most severely affected patients, and particularly in patients with thalassemia intermedia, prominent lobulated soft tissue densities may be noted in the posterior mediastinum and, to a lesser degree, in the anterior mediastinum or pelvis. These opacities result from extramedullary hematopoiesis (see the image below). CT scanning, which can evaluate the skeletal system in the axial plane, demonstrates that this proliferating marrow originates within the medulla of adjacent vertebral bodies, ribs, or pelvis.
Although extramedullary, it remains subperiosteal in location and, histologically, shows new bone formation. The presence of extramedullary hematopoiesis within the spinal canal may be associated with the development of spinal cord compression. Rarely, new bone formation within these proliferative subperiosteal masses may be extensive enough to result in osteomatous lesions of the ribs that are apparent radiographically (see the image below). Less frequently, similar osteomata may arise from the long bones.
Hematopoietic marrow is vascular, and in thalassemia, a 5- to 30-fold increase in activity may occur as a result of marrow hyperplasia and hypertrophy. Not surprisingly, this marrow proliferation is associated with increased blood supply, which may be seen radiographically as an enlargement of the nutrient foramina of the tubular bones, particularly the phalanges.
A similar enlargement is noted in other processes associated with increased blood supply to the medullary, including sickle cell disease variants, Gaucher disease, and infectious diseases (including leprosy), as well as noninfectious inflammatory conditions such as hemophilia. The calvarial widening, which occurs in association with marrow hypertrophy, may be associated with markedly enlarged and tortuous vascular impressions of the calvarium. Rupture of associated enlarged venous structures may constitute a potential sequela of moderate cranial trauma.
Premature fusion of the epiphyses
Premature fusion of the epiphyses is a characteristic finding in thalassemia. This finding first was described by Currarino and Erlandson,  who noted the abnormality in 14% of 79 patients with homozygous beta thalassemia. However, all of the patients were older than 10 years, resulting in an incidence of 23% in patients older than 10 years.
The finding may be unilateral or bilateral and is noted most commonly in the proximal humerus. Less frequently, it may be identified in the distal femur, proximal tibia, and proximal femur. The fusion is associated with a variable degree of shortening and is frequently eccentric, leading to angulation of the prematurely fused epiphyses. In the proximal humerus, this is associated with a humeral varus deformity. (See the image below.)
Currarino and Erlandson noted that a disproportionate number of patients (36%) had premature closure in the thalassemia intermedia subset of homozygous beta thalassemia.  An explanation for premature fusion has been suggested based on the relationship of the cortex and periosteum to the marrow proliferation (most marked in thalassemia intermedia), the fenestration of the metaphyseal cortex, the anatomy of the proximal humerus, and the forces normally exerted across the shoulder joint.
Response to therapy
The modern radiologist is unlikely to encounter radiographic thalassemic features other than in teaching files, on visits to Mediterranean countries, or in isolated patients never managed with hyper-transfusion therapy. This is because therapy by hyper-transfusion and chelation has improved the general health and the radiographic appearance of patients. As a radiologist, obtain a transfusional history for all patients under evaluation and be sure to understand the response of the skeletal system to therapy.
In a review of the ribs of 32 patients with homozygous beta thalassemia, the radiographic appearance of the ribs correlated with transfusional history. In this study, an overwhelming number of children hyper-transfused from an early age showed normal ribs. This was in contrast to patients who were not hyper-transfused until later in childhood or who were never hyper-transfused, who demonstrated a spectrum of radiographic rib abnormalities, the severity of which increased with the delay in initiating transfusional therapy.
The most striking rib changes were present in patients with thalassemia intermedia who were never transfused. Regression of rib abnormalities after transfusion was not uncommon; however, in approximately two thirds of patients, regression did not occur until after the introduction of hyper-transfusion therapy. The changes noted in the ribs appeared to reflect similar changes occurring in the appendicular skeleton.
Similarly, the size of the nutrient foramina in the phalanges and the vascular impressions in the calvarium are related to the age of onset and type of transfusional therapy. However, unlike the skeletal response to marrow proliferation, the enlarged vascular channels do not appear to regress with therapy but remain as a permanent record of earlier marrow changes.
In addition to the homozygous state, the thalassemic gene also may be present in the heterozygous state or in combination with some other abnormal hemoglobin (ie, HbC, HbE, HbH, HbS, HbLepore). With the exception of sickle cell thalassemia, in which radiographic changes may reflect vaso-occlusive phenomena, as well as the changes of marrow hypertrophy, the radiographic appearances of these variants are solely the result of marrow proliferation and, consequently, are dependent on the degree and duration of any anemia and the type of transfusion therapy.
The anemia that occurs in thalassemia minor, HbC thalassemia, and HbH thalassemia usually is mild; consequently, the radiographic changes typically are minimal or normal in these disorders. However, the anemia of HbE thalassemia and HbLepore thalassemia may be pronounced, with subsequent radiographic changes indistinguishable from those of homozygous beta thalassemia.
Degree of confidence
The radiographic features of thalassemia result from either a generalized marrow hypertrophy and hyperplasia, which may occur in other hemoglobinopathies, or a reticuloendothelial storage process, including Gaucher disease. These may be diagnosed radiologically with a high degree of confidence, although additional clinical and laboratory information may be required for the differential diagnosis of the hemoglobinopathies.
CT scanning is rarely of value, yet it may define the anatomy of change in complex bones and confirm the diagnosis of extramedullary hematopoiesis. Although CT scanning confirms the deposition of iron in the liver and other organs, correlation with organ damage, serum ferritin levels, and transfusional history is unsatisfactory.
Magnetic Resonance Imaging
Like CT, MRI rarely is of value, yet it may confirm the diagnosis of extramedullary hematopoiesis. Similarly, MRI confirms the deposition of iron in the liver and other organs, but correlation with organ damage, serum ferritin levels, and transfusional history is unsatisfactory. [4, 5, 6, 7]
Cholelithiasis is common in untreated thalassemia. Ultrasonography is the modality of choice when gallstones are suggested. 
Although ultrasonography may show gallstones in approximately 42% of sickle cell disease patients aged 15-18 years, the application of the same technique to a group of thalassemia patients maintained on hyper-transfusion therapy revealed gallstones in only 3.6% of patients in a similar age group. This reduction results from the more intensive transfusional regimen, which reduces activity of the patient's bone marrow, diminishes formation of the fragile erythrocytes, and consequently, limits production of excess bilirubin.